A school nurse evaluates a child who is chronically soiling underwear and shows no evidence of physical illness.
What is the priority nursing action?
Refer the child to a gastrointestinal specialist.
Reprimand the child gently to encourage control.
Report suspected encopresis and begin psychosocial evaluation.
Instruct the child to eat more fiber.
The Correct Answer is C
Choice A rationale
Referring the child to a gastrointestinal specialist might be considered later, but it is not the priority action. Since the child shows no evidence of physical illness, the most likely cause of chronic soiling is functional or psychological. Addressing the potential underlying psychosocial factors takes precedence over pursuing further physical diagnostics immediately.
Choice B rationale
Reprimanding the child gently is an inappropriate and potentially harmful action. Encopresis is often involuntary and can be a source of significant shame and distress for the child. Reprimanding can exacerbate these feelings, leading to further withdrawal and potentially hindering therapeutic progress rather than encouraging control or behavioral change.
Choice C rationale
Reporting suspected encopresis and beginning a psychosocial evaluation is the priority nursing action. Encopresis, in the absence of physical illness, strongly suggests a psychological or behavioral component. A psychosocial evaluation is critical to identify underlying stressors, emotional issues, or developmental factors contributing to the soiling behavior, facilitating appropriate intervention.
Choice D rationale
Instructing the child to eat more fiber is an intervention for constipation, which can be a contributing factor to encopresis. However, it's not the priority action when there's no evidence of physical illness and chronic soiling is present. Without addressing potential psychological factors, dietary changes alone are unlikely to resolve the complex issue of non-organic encopresis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
This statement is correct. Erythromycin 0.5% ophthalmic ointment is routinely administered to newborns to prevent ophthalmia neonatorum, which is an infection of the newborn's eyes caused by bacteria such as *Neisseria gonorrhoeae* or *Chlamydia trachomatis* acquired during passage through the birth canal.
Choice B rationale
This statement is incorrect. While the medication prevents neonatal ophthalmia caused by sexually transmitted infections (STIs), it is routinely administered to *all* newborns regardless of the mother's STI status. This is due to the potential for asymptomatic maternal infection and to ensure broad-spectrum prophylaxis.
Choice C rationale
This statement is correct. Cleaning the newborn's eyes from inner to outer canthus before administration removes any discharge or meconium that could interfere with medication absorption or introduce further contamination, ensuring optimal efficacy and preventing the spread of potential pathogens during application.
Choice D rationale
This statement is correct. Waiting at least one minute after administration before wiping the excess allows the medication sufficient time to spread across the conjunctival sac and be absorbed by the ocular tissues, maximizing its prophylactic effect against potential bacterial pathogens present on the eye surface.
Choice E rationale
This statement is incorrect. While the medication does treat conjunctivitis, its primary purpose in newborns is prophylactic, meaning it is given to *prevent* neonatal ophthalmia, not to treat existing conjunctivitis. It is administered to all newborns as a preventative measure against specific bacterial infections.
Correct Answer is B
Explanation
Choice A rationale
Focusing only on the area around the nipples is insufficient for a comprehensive self-breast exam. Breast tissue extends broadly from the collarbone to the bottom of the rib cage and from the armpit to the breastbone. Limiting the exam to one area could lead to missed abnormalities in other regions.
Choice B rationale
Using the pads of the fingers with varying pressure allows for thorough palpation of all breast tissue. Light pressure assesses superficial tissue, medium pressure evaluates deeper tissue, and firm pressure reaches the tissue closest to the chest wall, ensuring complete coverage and detection of abnormalities.
Choice C rationale
While lying down is one recommended position, conducting the exam only in this position is not sufficient. Performing the exam both lying down and standing (e.g., in the shower) allows for different tissue distributions and helps in detecting abnormalities that might be more palpable in one position over another.
Choice D rationale
Performing the exam every day is too frequent and unnecessary. Breast tissue changes throughout the menstrual cycle, and daily exams might lead to confusion regarding normal physiological variations. Monthly self-breast exams are recommended for consistency and to establish a baseline for individual breast tissue.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.